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8/3/2019 III. CV Training Guide Complete
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EssEntial nutrition actions FramEwork
2011
iii. training guidE
For community
voluntEErs
8/3/2019 III. CV Training Guide Complete
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The 1,000 Days Eort to
Reduce Child Undernutrion
What is 1,000 Days?1,000 Days is a global eort to jumpstart the implementaon of the Scaling Up Nutrion (SUN)
Framework and Roadmap for addressing undernutrion during pregnancy and early childhood. On
September 21, 2010, on the margins of the Millennium Development Goals summit, Secretary of State
Hillary Clinton and Irish Foreign Minister Michel Marn hosted an event to launch the eort, which
was endorsed by more than a dozen ministers and heads of organizaons. But 1,000 Days is more than
a single event. It is the start of a larger movement to focus aenon, align and increase resources, and
build partnerships to alleviate the suering caused by undernutrion among millions of people around
the world, especially pregnant women and children under 2 years of age.
What Are the Scaling Up Nutrion (SUN) Framework and Roadmap?The SUN Framework guides the internaonal community in eorts to combat undernutrion and builds
on the Paris-Accra principle of supporng country-led strategies. The Framework is endorsed by more
than 100 partners, including internaonal organizaons, naonal governments, civil society, and the
private sector The SUN Framework and Roadmap are grounded in the at scale implementaon of the
Lancet-endorsed nutrion acons that are evidence-based, cost-eecve intervenons that could have
enormous impact on reducing undernutrion.
Why 1,000 Days?
1,000 Days refers to the me from the start of a mothers pregnancy unl a child is two years old.
Children suering from undernutrion face physical stunng, mental impairment, higher suscepbility
to disease, increased risk of mortality, poorer performance in school, and lower future incomes. 1,000
Days also refers to a window of opportunity for the internaonal community to take acon to combatundernutrion.
How to Support the 1,000 Days?To jump-start the 1,000 Days in countries, the Core Group highly encourages its members to adopt such
tested and proveneld tools as the Essenal Nutrion Acons (ENA) Framework Trilogy training and
communicaon materials. Not only does the ENA Framework focus on the rst 1,000 days of life, but it
emphasizes targeng acon oriented nutrion messages and support -though mulple communicaon
channels- to reach under-twos and their mothers when they need it the most. The Core Group believes
that having many dierent eld groups using these same ENA tools will lead to harmonized eld
approaches that result in greater progress, synergies and nutrional impact. Such harmonizaon is
extremely crical as resources are scarce and the task ahead is enormous.
Where Can I Get More Informaon on the 1,000 Days?
Please visit www.thousanddays.org.
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Preface
TheEssentialNutritionActions(ENA)frameworkwasdevelopedwiththesupportofUSAIDandhasbeen
implementedacrossAfricaandAsiasince1997.Itisanoperationalframeworkformanagingthe
advocacy,planninganddeliveryofanintegratedpackageofpreventivenutritionactionsencompassing
infantandyoungchildfeeding(IYCF),micronutrientsandwomensnutrition.Usingmultiplecontact
points,ittargetshealthservicesandbehaviorchangecommunicationsupport(BCC)towomenandyoungchildrenduringthefirst1,000daysoflife-fromconceptionthroughthefirsttwoyearsoflife-
whennutrientrequirementsareincreased,therisksofundernutritionaregreat,andtheconsequences
ofdeficienciesmostlikelytobeirreversible.Alltheseactionshavebeenproventoimprovenutritional
statusandreducemortality.1
TheENAframeworkpromotesanutritionthroughthelifecycleapproach,addressingwomens
nutritionduringpregnancyandlactation,optimalIYCF(breastfeedingandcomplementaryfeeding),
nutritionalcareofsickandmalnourishedchildren(includingzinc,vitaminAandreadytousetherapeutic
foods),andthecontrolofanemia,vitaminAandiodinedeficiencies.TheENAframeworkemphasizes
thatmultipleprogramcontactpointsathealthfacilitiesandbeyondbeusedtoreachmothersand
childreninordertogiveandre-enforceENAmessages.Forexample,suchcontactpointscouldinclude
educationalsettings(e.g.primaryandsecondaryschoolsaswellaspre-serviceeducationcourses),
agricultureextensionservices(e.g.tosupportnutritionrelevantaspectsofavailability,accessand
utilizationofnutritiousanddiversefoods),aswellasavarietyofprogramplatformsatthecommunity
levelincludingprimaryhealthcareoutreach,childhealthdays,community-basedvolunteergroups,and
waterandsanitationprograms.Theintentistomaximizethesemultipleprogramopportunitiesand
communicationchannelstodeliverlifecycle-appropriatenutritionmessagesateveryopportunity
possibletopregnantwomenandmotherswithchildrenundertwoyearsatverybroadscale,inaddition
tootherkeychildcaregiversandinfluentialfamilymembers.
ThetrainingcomponentfortheimplementationoftheENAframeworkatboththehealthfacilityand
communitylevelscomprises atrilogyofmaterials asfollows:
I. TheBookletonKeyENAmessagesillustratesthekeyENAmessagesandcanbeusedbythoseimplementingandsupportinghealth,nutrition,andfoodsecurityprogramsforimproving
nutritionpracticesamongpregnantandlactatingmothersandchildrenundertwo.Itcanbea
resourcefortrainingcommunityorfacility-basedworkersorforpromotingbehaviorchangeat
thehouseholdlevel.Thegoalofthisbookletistomakeavailableanharmonizedsetof
messagesacrossallimplementingpartnersworkingacrossvariousprogramsandregionsinatargetedcountry.Thebookletsummarizes thekeyactionsthatmothersandcaretakerscan
take(withsupportfromotherfamilyandcommunitymembers)toimprovenutritionand
feedingpractices,therebypreventingmalnutrition.Eachmessagestates:
Whoshoulddotheaction Whattheactionis Whatthebenefitsoftheactionare
IIaandIIb.TheENAFrameworkTrainingGuideforHealthWorkersandHandoutsequipshealth
serviceproviderswiththetechnical,action-orientednutritionknowledgeandcounselingskills
neededtosupportpregnantwomen,motherswithchildrenundertwoyearsofage,andother
1BhuttaZ,AhmedT,BlackRE,CousensS,DeweyK,GiuglianiE,HaiderB,KirkwoodB,MorrisS,SachevHPS,ShekarM.(2008)
Whatworks?Interventionsformaternalandchildundernutritionandsurvival.MaternalandChildUndernutritionSeries.
Lancet;371:41740.
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keyfamilymemberstoadoptoptimalnutritionpractices.Thiscoursetranslatesup-to-date
internationalguidelinesintoaction-orientednutritionpractices.Thenegotiation/counseling
techniquesareadaptedfromtheTrialsforImprovedPractices(TIPS)andgobeyondjust
conveyingmessagestoprovidingsupportfortheadoptionofoptimalbehaviors.Infantfeeding
inthecontextofHIVandnutritionofwomenlivingwithHIVandAIDSarealsoaddressed,but
mightneedfurtherdevelopmentincountrieswithhighHIVprevalence.Guidelinestolinkthe
preventionofmalnutritionwithtreatmentviathecommunity-basedmanagementofacute
malnutritionarealsoincluded.Traininghandoutsaredistributedtoeachparticipantatthe
beginningoftheENAtraining.
III. TheENAFrameworkTrainingGuideforCommunityVolunteersequipssemi-literateorilliterate
CommunityVolunteerswiththebasicaction-orientednutritionknowledgeandcounselingskills
neededtosupportpregnantwomen,motherswithchildrenundertwoyearsandotherkey
familymemberstoadoptoptimalnutritionpractices.Thecoursealsocoversbasicskillsfor
identifyingchildrenwhoaremalnourishedincludingappropriatereferral.Thiscoursecanbe
incorporatedintoanytrainingatthecommunitylevel,includingonmaternal&childhealth,
communitymanagementofacutemalnutrition,HIV/AIDS,agriculturalproduction,food
security,ruraldevelopment,etc.
CountryAdaptation
ThegenericversionsoftheaboveENATrilogyhavebeentestedovertimeandarereadytobeusedin
newsettingsandcountries.Howeversomeadaptationsareneededtoensurethatthesematerialsare
countryandsituationspecific.Aguidetothekeyadaptationissuesareasfollows:
ENAMessages
ThespecificactionsrecommendedintheENAmessagesdontneedtobechangedastheyhavebeencompiledfromscientificresearchtosupportnutritionalstatus.However,theymayneed
tobeadjustedsomewhattomatchnationalguidelines(e.g.ageappropriatede-worming)or
mayneedtobeperiodicallyupdatedtoreflectnewglobaltechnicalguidance(e.g.infant
feedinginthecontextofHIV). Whilethespecificactionsareuniversal,theconceptsandlanguageusedtopromotethem
throughcounselingsessionswithmothersandotherchildcaretakersmustbeadaptedvia
formativeresearchtoensuretheirsuitabilityfordifferentculturalcontexts.Ifitisnotpossible
toconductformativeresearch,itisstillimportanttofield-testboththemessagesand
illustrationsusedinthisbookletwithasampleofmothers,fathersandotherchild-caretakers
suchasgrandmotherstoconfirmtheirsuitability.
FurtheradaptationoftheENAmessagesmaybeneededtospecifywhoisdoingtheaction(e.g.mothers,fathers,grand-mothers,etc)aswellasthebenefitsoftheactiontoensure
theirrelevanceandresonancewithintheparticularlocalityorsetting.Forexample,what
benefitswillmotivatemotherstopracticeexclusivebreastfeeding?Whattypesoflocal
complementaryfoods(staple+nutrient-richand/orenrichedfoods)areavailable?Whatlocalutensils(spoons,bowls,teacups)willhelpillustratethecorrectquantityoffoodthechild
needs?
Newillustrationsarentalwaysneededasexistingillustrationsoftencanbeeasilyadaptedandused.
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TrainingGuidesFocusingonCounselingSkillsandPracticumSessions
ThetwoENAFrameworktrainingguides arereadytobeusedanddonotrequirefurtheradaptation,excepttoincludecountry-specificmaternalandinfant&youngchildfeeding
messagesandprotocolsguidingmicronutrientsupplementation,theintegratedmanagementof
newbornandchildhoodillness,andthemanagementofacutemalnutrition. Theymayneedtobeperiodicallyupdatedtoreflectnewglobaltechnicalguidance.
BuiltintotheENAFrameworkTrainingGuidesaresessionscoveringthetechniquesofnegotiatingwithmotherstohelpthemtryandsucceedwithnewnutrition-relatedpractices,
andexercisesthroughwhichparticipantspracticeandbegintomastertheseskills.Thisincludes
roleplaysintheclassroomsettingandsitevisitstovillageswhereparticipantscanhonetheir
skillsworkingwithrealmothers.It cannotbeemphasizedenoughthatthesepracticalsessions
aretheheartofthetrainingprogramand shouldnotberemovedasthiswouldprofoundly
reducetheeffectivenessoftheENAtrainingaswellastheimpactoftheoverallENAsupportto
womenandyoungchildren.
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Acknowledgements
Wewouldliketoacknowledgethatthe BookletofKeyENAMessages andthetwoENAFramework
TrainingGuides tosupporttheimplementationoftheENAframeworkwouldnothavebeenpossible
withouttheeffortandsupportoverthepast15yearsofmanyinstitutionsandindividuals.
In1997,theUSAID-fundedBASICSprojectinitiatedtheapproachundertherubric theMinimumPackage
forNutrition orMinPak.Subsequentlytheapproachwasrenamedthe EssentialNutritionActions
(ENA)andwasexpandedconsiderablytoincludetrainingandIECmaterialsundertheUSAID-funded
LINKAGESProjectmanagedbytheAcademyforEducationalDevelopment(AED),wherewewereboth
involvedindesigningandimplementinglargescaleENAprogramsforMadagascar2andEthiopiafrom
1999to2006.
TheBookletofKeyENAmessages anditsrelatedENAFrameworktrainingguideshavebeenrecently
revisedandtestedwithinprojectsmanagedbyJohnSnowIncorporated(JSI)inEthiopiaandLiberia,and
byHelenKellerInternational(HKI)inanumberofcountriesacrossAfricaandtheAsia-Pacificregion.
MuchofthesupportforthisworkhascomefromUSAID,UNICEFandtheEuropeanUnion.
Stafffrommanyagenciesalsobroughttheirexpertiseandaregratefullyacknowledgedfortheir
contributionswithsupportfromUSAID,including:theAfricanRegionalCenterfortheQualityofHealthCare(RCQHC);theAfricasHealthin2010andFANTAProjectsmanagedbyAED;theWestAfricanHealth
Organization(WAHO);andtheEastCentralandSouthernAfricaHealthCommunity(ECSA-HC).UNICEF
hasalsoplayedakeyrole,especiallyinLiberiaandNiger,ashastheCarterCenterinEthiopia.National
trainingpartnersinanumberofcountrieshavebeencentraltothedevelopmentoftheENAframework
aswellasrelatedtrainingandIECmaterials.
CertainindividualswerealsoinstrumentalinhelpingustodevelopandtesttheoriginalENAtraining
coursesonwhichthepresentBookletofKeyENAmessages anditsrelatedENAFrameworkTraining
Guidesarebased.Theseindividualsinclude(byalphabeticalorder):MesfinBeyero,KristenCashin,
SerigneDiene,TesfahiwotDillnessa,MuluGedhin,PeterGottert,NancyKeith,AdbulselamJirga,Dorcas
Lwanga,RobertMwadime,HanaNekaTebeb,JenniferNielsen,AlbanRamiandrisoaRatsivalaka,Zo
Rambeloson,VoahiranaRavelojoana,PriscillaRavonimanantsoa,KindaySamba,MaryanneStone-JimenezandCatherineTemkangama.
2Guyon,AB,Quinn,VJ,Hainsworth,M,Ravonimanantsoa,P,Ravelojoana,V,Rambeloson,ZandMartin,L, Implementingan
integratednutritionpackageatlargescaleinMadagascar:TheEssentialNutritionActionsFramework.FoodandNutrition
Bulletin.30(3):233-44.TheUnitedNationsUniversity.2009.
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TheNutritionWorkingGroupofCOREGroupsupportedtheeffortstoupdatethetoolsandmakethem
morewidelyavailable.COREGroupfosterscollaborativeactionandlearningtoimproveandexpand
community-focusedpublichealthpractices.Establishedin1997inWashingtonD.C.,COREGroupisan
independentorganizationandhomeoftheCommunityHealthNetwork,whichbringstogetherCORE
Groupmemberorganizations,scholars,advocatesanddonorstosupportthehealthofunderserved
mothers,childrenandcommunitiesaroundtheworld.Thesetoolscanbeaccessedat
http://www.coregroup.org
AgnsB.Guyon,MD,MPH VictoriaJ.Quinn,PhD
JSIResearch&TrainingInstitute HelenKellerInternational
----------------------------------------------------------------------------------------------------------------
TheillustrationswereproducedundertheLINKAGESandJereoSalamaIsika(JSI)projectsinMadagascar,
theEssentialServicesforHeathinEthiopia(ESHE)andLINKAGESprojectsinEthiopia,andUNICEF
Liberia.
TheBookletonKeyENAMessages ,theENATrainingGuideforHealthWorkers,andtheENATraining
GuideforCommunityVolunteers canbeduplicatedifcreditisproperlygiven.Photosoncoverpage:
AgnsGuyon,UNICEFLiberiaandVictoriaQuinn.
TherecommendedcitationsareasfollowsforthesethreeENAdocuments:
Guyon,ABandQuinn,VJ.BookletonKeyEssentialNutritionActionsMessages. CoreGroup,Washington,D.C.,January2011
Guyon,ABandQuinn,VJ.EssentialNutritionActionsFrameworkTrainingGuideforHealthWorkers.CoreGroup,Washington,D.C.,January2011
Guyon,ABandQuinn,VJ.EssentialNutritionActionsFrameworkTrainingGuideforCommunityVolunteers.CoreGroup,Washington,D.C.,January2011
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TheSevenEssentialNutritionActions:Background
ThelandmarkLancetSeriesonMaternalandChildUndernutritionpublishedinearly2008estimatesthat
effective,targetednutritioninterventionstoaddressmaternalandchildundernutritionexistand,if
implementedatscaleduringthewindowofopportunity(conceptionandupto24monthsofage),could
reducenutrition-relatedmortalityanddiseaseburdenby25%.The EssentialNutritionActions
frameworkencompassessevenoftheseproveninterventionstargetingthiswindowbutalsorepresentsacomprehensivestrategyforreachingnearuniversalcoverage (>90%)withtheseinterventionsin
ordertoachievepublichealthimpact.ENAprogramsareimplementedthrough healthfacilitiesand
communitygroups .
Theapproachincludesensuringthatkeymessagesandservicespertainingtothesevenactionareasare
integratedintoallexistinghealthsectorprograms ,inparticularthosethatreachmothersandchildren
atcriticalcontactpoints(maternalhealthandprenatalcare;deliveryandneonatalcare;postpartum
careformothersandinfants;familyplanning;immunizations;wellchildvisits(includinggrowth
monitoring,promotion,andcounseling);sickchildvisits(includingIntegratedManagementofNewborn
&ChildhoodIllnessesandIntegratedCommunityCaseManagement);andOutpatientTherapeuticCare
duringCommunity-basedManagementofAcuteMalnutrition.
Theappropriatemessagesandservicesarealsointegratedtothegreatestextentpossibleintoprograms
outsidethehealthsector ,suchasagricultureandfoodsecuritycontacts;education(pre-service,
primaryandsecondaryschools)andliteracy;microcreditandlivelihoodsenhancement.
ImplementingtheENAframeworkentailsbuilding partnershipswithallgroupssupportingmaternaland
childhealthandnutritionprogramssothatmessagesareharmonizedandallgroupspromotethesame
messagesusingthesamejobaidsandIECmaterials.Ideallypartnersarebroughttogetheratthe
regionaland/ornationallevelstoagreeontheseharmonizedapproachesandto advocatewithpolicy
leadersfortheimportanceofnutritiontothenationseconomicaswellassocialdevelopment.
Messagesarecraftedassmalldo-ableactionsand behaviorchangecommunications (BCC)techniques
areusedtopromoteadoptionoftheseactions.Specialemphasisisgiventointerpersonal
communications(counselingofindividualmothers)thatarereinforcedbymassmediaandcommunityfestivalsandothermobilizingevents.Healthandcommunityagentsaretrainedtoemploynegotiations
forbehaviorchange,visitingmothersintheirhouseholdsorcommunitymeetingplaces(markets,
chores,womengroupsmeetings,etc)andhelpingthemanticipateandovercomebarrierstocarrying
outnewpractices.
Thecapacityforpromotingtheessentialnutritionactionsusingnegotiationsforbehaviorchangecanbe
strengthenedwithexistinggeneric trainingmodules3forhealthworkersandcommunityagents.
Whilethecontentremainsgenerallyfixed,thedetailsshouldbeadaptedthroughformativeresearchto
specificcountryandregionalcontexts.
3ThesetwomodulestogetherwithabooklethighlightingthekeyENAmessagescanbedownloadedfromtheCOREGroup
websiteontheNutritionWorkingGrouppage.
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TheSevenEssentialNutritionActions4
Allareequallyimportant.ThisENAlistisorganizedbyalifecycleapproach.
1. Promotionofoptimalnutritionforwomen2. Promotionofadequateintakeofironandfolicacidandpreventionandcontrolof
anemiaforwomenandchildren
3. Promotionofadequateintakeofiodinebyallmembersofthehousehold4. Promotionofoptimalbreastfeedingduringthefirstsixmonths5. Promotionofoptimalcomplementaryfeedingstartingat6monthswithcontinued
breastfeedingto2yearsofageandbeyond
6. Promotionofoptimalnutritionalcareofsickandseverelymalnourishedchildren7. PreventionofvitaminAdeficiencyinwomenandchildren
4COREGroup.NutritionWorkingGroup.NutritionProgramDesignAssistant:AToolforProgramPlanners,Washington,DC:
2010
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-1-
INTRODUCTION
ThepurposeofthistrainingguideistotrainCommunityVolunteers(CV)inkeyinfantandyoungchild
feedingpractices/messages,theimportanceofmicronutrientsandwomensnutrition,andincrucial
negotiation,andinterpersonalcommunicationskills.TheknowledgeandskillswillenableCommunity
Volunteerstohelpmothers/caregiversoptimallyfeedtheirinfantsandyoungchildrenandtakecareof
theirownnutritionalneeds.ThetrainingalsoprovidesanopportunityforsupervisorsandCommunity
Volunteerstolearntogetherandpracticecoachingtoimproveperformance.
TrainingAgenda
Thisthree-daytrainingguideisorganizedinasequencetofacilitatelearningandallowopportunitiesto
practicenegotiationskills
Thesessionsforeachdayoutlinespecificlearningobjectives,activitydetails,materials/handouts,
durationandmethodologiesforlearningactivities.
TrainingMethodology
ThetrainingguideappliestheprinciplesofBehaviourChangeCommunicationtopromotesmall,do-able
actions,andthewidelyacknowledgedtheorythatadultslearnbestbypracticeandreflectionontheir
experiences.Attemptshavebeenmadetomakethetrainingsessionsrelevanttotheneedsof
participantsandtheircommunities.
Thisparticipatoryapproachusestheexperientiallearningcyclemethodandallowsparticipantsthe
hands-onperformanceofskillsasameansofacquiringthem.Thecourseemploysavarietyoftraining
methods:demonstrations,practice,discussions,casestudies,groupdiscussions,androleplays.
Participantswilllearntoactasresourcepersonsforbreastfeedingmothers,pregnantwomen,and
mothers/caregiversofyoungchildren.
Respectforindividualtraineesiscentraltothetrainingandsharingofexperiencesisencouraged
throughout.Participantscompletepreandposttrainingassessmentquestionnairestoallowtrainersto
measuretheirprogress.
TrainingLocation
Whereverthetrainingisplanned,asiteshouldbeselectedclosetothetrainingfacilityandreadily
availabletoallowthepracticumfornegotiationwithmothers/caregiversondo-ableinfantandyoung
childfeedingpractices.Preparethepracticumsitebycoordinatingwiththeclinicand/orcommunity,
alertingthemtothearrivalofparticipantsandarrangingforspaceforpracticingnegotiationskillswith
actualmothers/caregivers.Itisoptimaltohaveonefacilitatorforevery6-8participantsforthissession.
MaterialsNeededfortheTraining
Stationary Flipchartstands 1 Flipchartpapers 50sheets Markers 1boxblack+1boxofcolor Maskingtape 1roll Participantsregistrationforms 1perday
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-2-
Teachingaids
Dolls 3* Breastmodels 3 Foodsfordisplay avarietyoflocallyavailablefoods BookletonKeyENAmessages 1perparticipant ChildMUACtapes 1perparticipant AdultMUACtapes(optional) 15MUACtapesAdvancePreparationforFieldTrip
Oneweekinadvance,makeanappointmentatthehealthclinictodothefieldpracticeduringimmunizationorweighingsessions.
Oneweekinadvance,makeanappointmentwiththecommunityhead/leaderorthecommunityhealthagenttorequestpermissionforvillagevisits.
Confirmthedaybeforethevisitandspecifythenumberofmothersneeded(atleast10).Realmothersandbabiescanbealsoinvited.
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-3-
DAY1
WOMENNUTRITIONANDOPTIMALBREASTFEEDING
DURATION
Session
1
Introduction
Pre-test
LearningObjectives
RoleoftheCommunityVolunteer
1hour
Session
2
Thecycleofmalnutrition
Keymessageswomansnutrition(pregnancy)1hours
Session
3
Advantagesofbreastfeeding
Earlyinitiationofbreastfeeding
Exclusivelybreastfeeding0-6months
Demonstrationofcorrectpositioningandattachment
2hours
LUNCH(1hour30minutes)
Session
4Negotiationandcasestudies
2hours
15minutes
DAY2
COMPLEMENTARYFEEDINGANDNUTRITIONOFTHESICKCHILD
Session
5
Screeningformalnutrition
Referringachildwhoismalnourished2hours
Session
6
KeymessagesoncomplementaryfeedingNutritionmanagementofthesickchildormalnourishedchild
Availablelocalfoods
3hours
LUNCH(1hour30minutes)
Session
7Negotiationandcasestudies
2hours
15minutes
DAY3
FIELDPRACTICEANDPLANNING
Session8
Fieldpracticum3hours
30minutes
Session
9
Summary
Developmentofactionplans
CLOSINGCEREMONY
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-4-
SESSION1
INTRODUCTION:WHYWEAREHERE?
LearningObjectives
Bytheendofthesession,participantswillbeableto:
Begintonamefellowparticipantsandfacilitators. Discussexpectations. Explainwhywearehere?Activities
Activity1.1 Introduction(15minutes)andreviewofthelearningobjectives
Activity1.2 Pre-testofinfantandyoungchildfeedingpractices(15minutes)
Activity1.3 Administrationandhousekeeping(5minutes)
Activity1.4 DiscusstheroleofCommunityVolunteers(CVs)(25minutes)andhowandwhenthey
canimprovenutritionpractices
FacilitatorsNote1:Learningobjectives
FacilitatorsNote2:RoleofCommunityVolunteerandEssentialNutritionActions
TotalTime 1hourACTIVITY1.1 Introductionandreviewtheobjectives(15minutes)
Methodology Askparticipantstointroducethemselves;eachparticipantintroduceshername,whereshelives,
andwhyshecametothistraining.
ACTIVITY1.2 Pre-testofinfantandyoungchildfeedingpractice
(15minutes)
Methodology Askparticipantstoformacircleandsit(orstand)sotheirchairbacksarefacingthecenter. Explainthatquestionswillbeaskedandparticipantswillbeaskedtoraisetheirhandiftheythink
theanswerisYesandnottoraisetheirhandiftheythinktheanswerisNo.(Refertopages
11/12forquestionsand13/14foranswers)
Onefacilitatorreadsthequestionsandanotherfacilitatorrecordstheanswersandnoteswhichtopicsmaybecausingconfusion.
Adviseparticipantsthatthesetopicswillbediscussedingreaterdetailduringthetraining.
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-5-
Pre-TestandPost-TestforCommunityVolunteers
# PRE-TEST YES NO
1 Isitimportanttoputthenew-bornbabytothebreastimmediatelyafter
birth?
2 Isitnecessarytogivebabiesyoungerthan6monthsofagewaterseveraltimesperday,becausetheyneedwatertosurvive?
3 Ifat3months,themotherthinksthathermilkisdecreasing,shouldshe
nursethebabymorefrequently?
4 At6months,shouldamotherbegingivingherbabyfoodsinadditionto
breastmilk?
5 After6months,isitgoodtogivetheinfantonlybreastmilk?
6 Isawateryporridgeabetterfoodfora6-month-oldbabythansoftenriched
porridge?
7 Whenababyreaches8months,doesthebabyneedtoeat2-3timesaday,
inadditiontobreastmilk?
8 At12monthsofage,canababyeatthefamilyfoodandalsoneedtohavesnacksbetweenmealsastheirstomachsaresmall?
9 Whenayoungchildover6monthshasdiarrhea,doesthemotherneedto
increasethefrequencyofbreastfeedingandthefrequencyoffeedingother
liquidsandfoods?
10 DoinfantsneedtotakeaVitaminAcapsuleonceayear?
11 Shouldthemotherwaituntilasickchildishealthybeforegivinghim/her
morefoods?
12 Tohelpensureahealthypregnancy,dopregnantwomenneedtoeatan
extramealperday,especiallyinthethirdtrimester?
13 Dobreastfeedingmothersneedtoeattwoextramealsperday?
14 Toprotectherselfandherbaby,shouldthemothertakeonecapsuleof
VitaminAafterbirth(orwithin8weeksafterbirth)?
15 Duringpregnancy,manywomenfeelweakanddizzy.Isthisnormal?
16 Willbreastfeedingachildyoungerthan6monthsofageatleast8-10times
perdayhelptodelayanotherpregnancy?
17 Isittruethatthereisnothingthatcanbedoneaboutintestinalworms?
18 Topreventweakness,fatigueandproblemsduringbirth,shouldpregnant
womentakeirontablets?
19 Shouldfamiliesalwaysuseiodizedsaltwhencookingfood?
20 Arechildrenwhosleepunderantreatedmosquitonetprotectedagainst
malaria?
21 Ifamotheronlybreastfeedsachildwhoisunder2yearsofage4-5timesper
day,willherbabybeatriskofbeingmalnourished?
22 Shouldamotherworryifafterillness,herinfantdoesnoteat?
23 Shouldchildren12-24monthsofageeat4ormoretimesaday?
24 Shouldchildrenunder5whoaretoothinbereferredtoahealthfacility?
25 IsoneoftheresponsibilitiesofCommunityVolunteerstopracticeoptimal
infantandyoungchildfeedingwiththeirownchildren?
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Pre-TestandPost-TestforCommunityVolunteers-Answers
# PRE-TEST YES NO
1 Isitimportanttoputthenew-bornbabytothebreastimmediatelyafter
birth?x
2 Isitnecessarytogivebabiesyoungerthan6monthsofagewaterseveraltimesperday,becausetheyneedwatertosurvive?
x
3 Ifat3months,themotherthinksthathermilkisdecreasing,shouldshe
nursethebabymorefrequently?x
4 At6months,shouldamotherbegingivingherbabyfoodsinadditionto
breastmilk?x
5 After6months,isitgoodtogivetheinfantonlybreastmilk? x
6 Isawateryporridgeabetterfoodfora6-month-oldbabythansoftenriched
porridge?
7 Whenababyreaches8months,doesthebabyneedtoeat2-3timesaday,
inadditiontobreastmilk?x
8 At12monthsofage,canababyeatthefamilyfoodandalsoneedtohavesnacksbetweenmealsastheirstomachsaresmall?
x
9 Whenayoungchildover6monthshasdiarrhea,doesthemotherneedto
increasethefrequencyofbreastfeedingandthefrequencyoffeedingother
liquidsandfoods?
x
10 DoinfantsneedtotakeaVitaminAcapsuleonceayear? x
11 Shouldthemotherwaituntilasickchildishealthybeforegivinghim/her
morefoods?
12 Tohelpensureahealthypregnancy,dopregnantwomenneedtoeatan
extramealperday,especiallyinthethirdtrimester?x
13 Dobreastfeedingmothersneedtoeattwoextramealsperday? x
14 Toprotectherselfandherbaby,shouldthemothertakeonecapsuleofVitaminAafterbirth(orwithin8weeksafterbirth)?
x
15 Duringpregnancy,manywomenfeelweakanddizzy.Isthisnormal? x
16 Willbreastfeedingachildyoungerthan6monthsofageatleast8-10times
perdayhelptodelayanotherpregnancy?x
17 Isittruethatthereisnothingthatcanbedoneaboutintestinalworms? x
18 Topreventweakness,fatigueandproblemsduringbirth,shouldpregnant
womentakeirontablets?x
19 Shouldfamiliesalwaysuseiodizedsaltwhencookingfood? x
20 Arechildrenwhosleepunderantreatedmosquitonetprotectedagainst
malaria?x
21 Ifamotheronlybreastfeedsachildwhoisunder2yearsofage4-5timesperday,willherbabybeatriskofbeingmalnourished? x
22 Shouldamotherworryifafterillness,herinfantdoesnoteat? x
23 Shouldchildren12-24monthsofageeat4ormoretimesaday? x
24 Shouldchildrenunder5whoaretoothinbereferredtoahealthfacility? x
25 IsoneoftheresponsibilitiesofCommunityVolunteerstopracticeoptimal
infantandyoungchildfeedingwiththeirownchildren?x
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ACTIVITY1.3 AdministrationandHousekeeping
(5minutes)
ACTIVITY1.4 DiscusstheroleofCommunityVolunteers(CVs)andhowthey
canimprovenutrition(25minutes)
Methodology Facilitatorintroduceslearningobjectives(FacilitatorsNote1) DiscussWhoareCommunityVolunteers?(FacilitatorsNote2)WhoareCommunityVolunteers?
Discussionquestions:
1.Whoisresponsibleforthehealthofthecommunity?
2.Whatrolecancommunitymembersplaytosolvetheirhealthproblems?
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FacilitatorsNote1
LearningObjectives Attheendofthetraining,theparticipantswillbeableto:
1. Describethekeymessagesandpracticesforoptimalbreast-feeding.2. Describethekeymessagesandpracticesforadequatecomplementaryfeeding.3. Describethekeymessagesandpracticesforadequatewomensnutritionduringpregnancyand
lactation.
4. Describethekeymessagesandpracticesforcontrollingmicronutrientdeficiencies(VitaminA,Anaemia,Zinc,andIodine).
5. Negotiatewiththemothers(toencouragethem)totryoneimprovedpracticeinoneofthelearningobjectivesmentionedaboveandtoreinforcetheadoptionofthenewpractice.
6. UsetheMUACmeasurementtoidentifychildrenwhoaremalnourishedforcounselling,follow-up,andorreferral.
7. Explaintheirroleascounsellorswhoareabletolistento,giveconstructivefeedback,andpracticepositivecoaching.
8. Developathree-monthactionplanoftheactivitiestheywillimplementuponreturntotheircommunities.
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FacilitatorsNote2
RolesofCommunityVolunteersandHow/WhenTheyCanCommunicateMessagesRoles
Serveasarolemodelinthecommunitybypracticingoptimalinfantandyoungchildfeedingpractices.
Communicatekeymessagestofriendsandneighbors. Screenchildrenformalnutrition. Refermothersandchildrenwhoneedtreatmenttothehealthcenter/facility. Actasabridgebetweenthecommunityandhealthfacilities. Supportcommunitymemberstosolvetheirownhealthproblems. Encouragefamiliestoundertakedo-ableactions.Opportunitiestocommunicatemessages
Duringhomevisits Duringoutreachforimmunization Duringnutritionscreening Duringmarketdays,whilefetchingwater,andatwork Duringdeliveries Duringvisitstosickneighbors Duringreligious,cultural,oreconomical/socialmeetingsorgatheringsWaystocommunicatemessages
Throughnegotiations,inwhichyouaskthemothertotryanewpractice ThroughgroupdiscussionsattheNutritionScreeningCentre Throughdrama,roleplay,songs,andotheractivities Duringoutreachforimmunization DuringChildHealthDays
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TheEssentialNutritionActionsandContactPoints
forCommunityVolunteers
Examplesof whatcanbedone1.FocusontheEssentialNutritionActions:
Optimalbreastfeeding Complementaryfeedingtobreastfeeding Feedingasickchild Womensnutrition ControlofVitaminAdeficiency Controlofanemia Controlofiodinedeficiencydisorders2.Organizecommunitysupportgroupsonvariousthemesdiscussedinthistraining
3.Discussfeedingpracticeswithmothers(individually)particularlyifthechildismalnourished:
Duringhomevisitsorinformalencounters Duringnutritionscreeningsessions Duringcommunitymanagementofacutemalnutritionsessions DuringHealthDays Atthehealthfacilitiesoroutreachsessionsduringimmunizations,ANC(AntenatalClinic),Growth
MonitoringandPromotion
4.Discusshomegardening,particularlylinkedwithdevelopmentagentsoragricultureextension
workers
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SESSION2
WOMENSNUTRITIONDURINGPREGNANCYIMPORTANCEOFMICRONUTRIENTS
LearningObjectives
Bytheendofthesession,participantswillbeableto:
Describethemalnutritionlifecycle. Explainkeypractices/messagespertainingtowomansnutrition. Negotiatewithwomentoimprovekeypracticesfortheirnutrition. Describetheimportanceofironfolicacidsupplementationchildrenandwomen,deworming,and
usingiodizedsaltduringpregnancy.
Activities
Activity2.1 Whynutritionofwomenisimportant.Discussthelifecycle(30minutes)
Activity2.2 Messagesandadditionalinformationforadequatenutritionforapregnantwoman(45
minutes)
TotalTime 1hourMaterials
Flipcharts,paper,markers,andmaskingtape BookletonKeyENAMessages(containsillustrationsusedbelowandinsubsequentsessions)Illustration1 Nutritionofpregnantwoman
Illustration2 Ironfolicacidsupplementationanddewormingduringpregnancy
Illustration3 Preventionofmalariaandanemia
Illustration4 Useofiodizedsalt
ACTIVITY2.1. Whynutritionofwomenisimportant?
Methodology:Facil itateddiscussion(1hour) Brainstormontheeffectivepracticesofnutritionwithinthecommunity,theimportanceofwomens
nutrition.Alsodiscusstherolethattheoldestwomanandhusbandinthehouseholdplayinfood
accessanddistribution.
Explainthecycleofmalnutritionfromonegenerationtoanotheranddescribeinterventionsthatmakeitpossibletobreakthisviciouscycle.Usepaperfigurines,photographs,orimages
representingababy,ayounggirlbetween6and8yearsold,ateenagerbetween13and14years
old,apregnantyoungwoman,andayoungwomanandhernew-bornbaby.Foreachstageofa
womanslife,askquestionssuchasthefollowing:
Whatwouldhappenifthisbabygirl(orthisgirlorwoman)didnotreceiveallthenutritionthatsheneeds?
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Whatwillhappentothisgirlwhenshereaches8yearsofage?(Orbecomespregnantorhasababy)?
Whydoesthisproblempersistwhenthebabygrowsandbecomesmother? Whatcanbedonetopreventthisfromcontinuing?
Concludethatitisimportanttoimprovewomensnutritionforthebenefitofthebaby,thehousehold,andthecommunity.
ACTIVITY2.2 Womensnutritionduringpregnancyandimportanceofmicro-
nutrients
Methodology:Facil itateddiscussion (45minutes) Asktheparticipantstoreviewthepictures. Askthemthequestionssuggestedforeachillustration. Readthemessage,andreadtheadditionalinformationonebyone. Asktheparticipantstodiscussthemessagesandadditionalinformation,comparethesetocurrent
practicesintheircommunities,andhowtheymighttrytoconvincemembersofthesecommunitiesthattherecommendedpracticescanimprovethehealthofmothersandchildren.
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SESSION3
OPTIMALBREASTFEEDING
LearningObjectives
Bytheendofthissession,participantswillbeableto:
Describekeypracticesforoptimalbreastfeeding. Explaintheadvantagesofbreastfeedingforthemotherandchild. Describekeypracticesandmessagesforoptimalbreastfeeding. Discusswithmothers/caregivershowtoadoptbetterfeedingpractices. Activities
Activity3.1 Discussadvantagesofbreastfeeding,keyoptimalbreastfeedingpractices,andreview
correctpositioningandattachment(2hours)
TotalTime 2hoursMaterials
Flipchart,papers,markers,maskingtape BookletonkeyENAmessages Dollsand/orbabiesFacilitatorsNote3:Howtoexplainthebenefitsofbreastfeeding?
Illustration5 Earlyinitiationofbreastfeeding
Illustration6 Exclusivebreastfeedingto6monthsofage
Illustration7 Frequencyofbreastfeeding
Illustration8 Correctpositioningforoptimalbreastfeeding
Illustration9 Properattachmentforoptimalbreastfeeding
Illustration10 Othercorrectpositioning
Illustration11 Nutritionoflactatingwomen
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ACTIVITY3.1 Discusskeyoptimalbreastfeedingpractices
(2hours)
Methodology:Brainstorming(30minutes)Dividetheparticipantsintofourgroups.
Askeachgrouptodiscussthefollowingtopics:1.Advantagesofbreastfeedingfortheinfant
2.Advantagesofbreastfeedingforthemother
3.Advantagesofbreastfeedingforthefamily
4.Advantagesofthebreastfeedingforthecommunity/nation
Assignatopictoeachgroup:thefourgroupshave15minutestodiscussalltheadvantagestheycanthinkof.Theyneedntwritebutrathergiveoralpresentations.
Eachgrouppresents. Thefacilitatorcompletesbyaddinganypointthathasbeenmissed.
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FacilitatorsNote3
Howtoexplainthebenefitsofbreastfeeding?
Fortheinfantandyoungchild,breastmilk Savesinfantslives. Isacompletefoodfortheinfantbecauseitcontainsbalancedproportionsandsufficientquantityof
allthenutrientsneededduringthefirst6months.
Containsantibodiesthatprotectagainstdiseases,especiallyagainstdiarrhoeaandrespiratoryinfections.
Theinfantbenefitsfromthecolostrum,whichprotectshim/herfromdiseases.Thecolostrumactsasalaxativecleaningtheinfantsstomach.
Promotesadequategrowthanddevelopment,thuspreventingstunting.
Isalwaysclean. Isalwaysreadyandattherighttemperature. Iseasytodigest.Nutrientsarewellabsorbed. Protectsagainstallergies.Breastmilkantibodiesprotectthebabysgut,preventingharmful
substancesfrompassingintotheblood.
Containstherightamountofwatertomeetthebabysneeds.(Upto80%ofbreastmilkiswater.) Helpsjawandteethdevelopment;sucklingdevelopsfacialmuscles. Frequentskin-to-skincontactbetweenmotherandinfantleadstobetterpsychomotor,emotional,
andsocialdevelopmentoftheinfant.
Forthemother Puttingthebabytothebreastimmediatelyafterbirthfacilitatestheexpulsionoftheplacenta
becausethebabyssucklingstimulatesuterinecontractions.
Reducesrisksofbleedingafterdelivery. Whenthebabyisimmediatelybreastfedafterbirth,breastmilkproductionisstimulated. Immediateandfrequentsucklingpreventsengorgement. Breastmilkisavailableatanytimeandanywhere,isalwaysclean,nutritious,andattheright
temperature.
Itiseconomical. Stimulatesthebondbetweenmotherandbaby. Reducesthemothersworkload(notimeisinvolvedinboilingwater,gatheringfuel,orpreparing
milk).
Reducesrisksofpre-menopausalbreastandovariancancer. Breastfeedingismorethan98%effectiveasacontraceptivemethodduringthefirst6months
providedthatbreastfeedingisexclusiveandperiodsdonotreturn.
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Methodology:Demonstrationanddiscussion(1hour30minutes)ImmediateInitiation
ShowIllustration5. Asktheparticipantstoanswerthequestionsontheillustration. Readthemessageanddiscusstheadditionalinformation. Asktheparticipantstodiscussthemessagesandadditionalinformation,comparetocurrent
practices,andhowtoconvincethatthepracticecanimprovethehealthofmothersandchildren.
Breastfeedingexclusivelyuntil6monthsofage
ShowIllustrations6and7. Asktheparticipantstoanswerthequestionsontheillustrations. Readthemessageanddiscusstheadditionalinformation. Asktheparticipantstodiscussthemessagesandadditionalinformation,comparetocurrent
practices,andhowtoconvincepeoplethatthepracticecanimprovethehealthofmothersand
children.Demonstrationofcorrectpositionandattachment
Usingadoll(orababy),thefacilitatordemonstratesthecorrectpositionandattachmenttothebreast.
Thefacilitatoraskstheparticipantstodescribewhattheysee. ShowIllustrations8,9,and10. Answerthequestionsontheillustrations. Readtheadditionalinformation. Comparewiththecurrentpractices,andhowtoimprovethem.
Womensnutritionduringlactation
ShowIllustration11. Asktheparticipantstoanswerthequestionsontheillustration. Readthemessageanddiscusstheadditionalinformation. Asktheparticipantstodiscussthemessagesandadditionalinformation,comparetocurrent
practices,andhowtoconvincepeoplethatthepracticecanimprovethehealthofmothersand
children.
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SESSION4
HOWTONEGOTIATEWITHMOTHERS,CAREGIVERS,FATHERS,GRANDMOTHERS
ONWOMENSNUTRITIONDURINGPREGNANCYANDOPTIMALBREASTFEEDING
LearningObjectives
Bytheendofthesession,participantswillbeableto:
Explainthestepsofnegotiation(GALIDRAA). Practicenegotiationwithpregnantwomenandamotherofababy0-
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ACTIVITY4.1 Demonstrateandpracticenegotiationforpregnantwomen
andwomenofbaby0-
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FacilitatorsNote4
ListeningandLearningSkills
1.Usehelpfulnon-verbalcommunication.
a.Keepyourheadlevelwithmother
b.Payattention
c.Nodhead
d.Taketime
e.Appropriatetouch
2.Askopen-endedquestionsthatstartwithwhat,why,how,orwhereratherthanquestionsthat
requireayesornoansweronly.
3.Useresponsesandgesturesthatshowinterest.
4.Reflectbackwhatthemothersays.
5.Empathizeshowthatyouunderstandhowshefeels.
6.Avoidusingwordsthatsoundjudgementale.g.whatyouaredoingiswrongorbad.
FacilitatorsNote5
ObservationChecklist: (GALIDRAA)1. Greetsthemotherandestablishesconfidence.2. Asksthemotheraboutcurrentbreastfeedingpractices.3. Listenstowhatthemothersays.4. Identifiesfeedingdifficulties,ifany,causesofthedifficulties,andselectswiththemotherone
difficultytoovercome.
5. Discusseswiththemotherdifferentfeasibleoptionstoovercomethedifficulty.6. Recommendsandnegotiatesdoableactions:PresentsoptionsandNEGOTIATESwiththe
mothertohelpherselectonethatshecantry.
7. MotherAgreestotryoneormoreoftheoptions,andmother repeatstheagreeduponaction.8. MakeanAppointmentforthefollow-upvisit.
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FacilitatorsNote6
Roleplaydonebyfacil itator(s) Faithis9monthspregnantanditishersecondpregnancy.Inherfirstdelivery,shedidnotgive
colostrumtothebaby.Sheisnotplanningtogivethecolostrumthistimeeitherbecauseshethinksitisbadforthebaby.
TheCommunityVolunteer
TheCommunityVolunteertalkswithFaithandexplainsearlyinitiationofbreastfeedingafterbirth,and
thatthispracticeisimportantbecausethefirstmilk(colostrum)helpsprotectthebabyfrominfections
anddiseases.TheCommunityVolunteeralsospeakstoheraboutexclusivebreastfeedingforthefirst6
monthsandrecommendsnotgivingthebabyanywater.
TheFacilitator
Discusseskeystrategiesthatwillleadthemothertotrythenewbehaviorandsolvethepotential
problems.Thesestrategies,forexample,consistofaskingothermembersofthefamilytotakepartin
thediscussionandtrythenewbehaviorthemselves.
Exampleof possiblefollow-upnegotiationvis its toFaith:Visit#2:Followup
Situation:ThehealthworkervisitsFaithtoaskherwhethershehasbeenableto exclusively
breastfeedAmosduringthepastweek.Faithanswersthatitseemedtoherthat,forthefirsttwo
days,Amossuckledforthewholeday.Butshedid exclusivelybreastfeed.Shesayshermotheris
comingtoseeherthefollowingweekandwillsurelyadvisehertofeedAmosotherthingsbesides
breastmilk.
Visit#3:Maintainthepracticeand/ornegotiateanotherpractice
Situation:Amosisnow5monthsold,andFaithhasexclusivelybreastfedhimfor5months.ShepointsouttothehealthworkerthatAmoshashadneitherdiarrheanoracold.
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FacilitatorsNote7
PracticeCaseStudies:WomansNutritionduringPregnancy
CaseStudy1YouvisitHawawhois4monthspregnant.Hawahasnotyetvisitedthehealthclinic.
TheCommunityVolunteer
Thecommunityvolunteer(CV)asks,listenstoHawa,andidentifiesproblemsandcausesforthe
problems.Inthisparticularcase,themainproblemisthatHawahasnotbeenattendinganante-natal
clinic.
TheCVhastoexplaintheimportanceof:
Goingtoante-natalclinictoensurethatthepregnancyisgoingwell,toreceiveTTvaccines,iron-folicacidsupplementation,dewormingmedicine,anti-malarialtablets,andadditionalcounseling
andsupport. Eatingwell,oneadditionalmealeachday,anddiversifieddietasmuchaspossible(animalsource
foods,fruitsandvegetables).
Usingiodizedsalt.
CaseStudy2 Quetais21.Shetellsyouthatshehasthreedaughtersbetweentheagesof2and6.Whatthemeswill
youtrytodiscusswithQueta?
TheCommunityVolunteer
TheCVasksandlistenstothepracticeandidentifiesproblemsandthecausesfortheproblems.
Inthisparticularcase,themainproblemisthatQuetahadchildrentooclosetoeachotherstarting
whenshewasveryyoung.TheCVhastoexplaintheimportanceofeatingwell,asthesepregnancies
mighthavebeendifficultforherbody;shehastogotobecheckedforanemia.Quetashouldwaitat
leastthreeyearsbeforethenextchildandtheCVneedstorecommendthatshespeakwithherhusband
aboutfamilyplanningtodelayanotherpregnancy.
CaseStudy3Massaisinherlastmonthofpregnancyanddoesnotknowwhereshewillgivebirth.
TheCommunityVolunteer
TheCVneedstoaskandlistentothecurrentpracticeandidentifyproblemsandcausesforthe
problems.
Inthisparticularcase,themainproblemisthatMassahastobeconvincedtocomeinanddeliverher
babyatthehealthfacility.Sheneedstobecheckedforanemia,andgetiron/folicacidsupplementation
anddewormingmedicine.Massaalsoneedstobecounselonbreastfeedingearly,withinthefirsthour
afterbirth,beforetheplacentaisexpelled.Shealsoneedstobetoldoftheadvantagesofonly
breastfeedingherbaby,nootherfoodorwater,untilthebabyis6monthsold.
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CaseStudy4Fatuis6monthspregnant,andhasafever.Shefeelsweak.
TheCommunityVolunteer
TheCVneedstoaskandlistentothecurrentpracticeandidentifyproblemsandcausesfortheproblems.
Inthisparticularcase,themainproblemisthatFatuhastobeconvincedtocometothehealthfacility
andbetreatedformalaria,becheckedforanemia,andreceiveante-natalcare.TheCVneedstoexplain
thatshehastosleepunderatreatednettoavoidgettingmalaria,whichisharmfulforherandthebaby.
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FacilitatorsNote8
PracticeCaseStudies:OptimalBreastfeeding
CaseStudy1Yamahis9monthspregnant.Asthisisherfirstpregnancy,shewantsthebabytobestrongandingood
health,butsheistootimidtotalkaboutbreastfeeding.Hermother-in-lawdecidedthatduringthefirst
threedaysafterchildbirth,Yamahwillgivepeppersouptothebaby.Shebelievesthatthefirstyellow
milkisbad.
TheCommunityVolunteer
TheCVneedstoaskandlistentothecurrentpracticeandidentifyproblemsandcausesforthe
problems.
Inthisparticularcase,themainproblemisthatYamahsmother-in-lawdoesnotunderstandthe
importanceofcolostrum.TheCVasksthemother-in-lawtojoinYamahandhim/herself.TheCVexplainstothetwowomentheimportanceofearlyinitiationofbreastfeedimmediatelyafterthechildbirth. The
firstmilkorcolostrumisyellowbecauseitcontainsvitaminsanditwillprotectthebabyfromthe
diseases.Thismilkisarichinfatsandinfoodsanditallowsthebabytostartahealthylifefromthe
beginning,andthebabywillbestrong.TheCVexplainsthatbreastfeedingthebabystimulatesthe
dischargeoftheplacenta,thuspreventingthebleedingofthemotherafterchildbirth.Italsohelpswith
milkproduction;whenthebabyissucklingthemothersbodybeginstoproducethebreastmilkforthe
baby.
TheCVasksthemother-in-lawwhatshethinksoftheexplanations.Sheanswersthatinherdays,they
didnotbelieveinthesethings.ButsheaddsthatshehasheardthatwhattheCVsrecommendswas
triedbyawomaninhervillageandallwentwellandthebabyisingoodhealthandgrowingwell.After
thediscussion,Yamahsaysshewilltrytoputthebabytothebreastbeforetheybathethebabyandevenbeforetheplacentaisdischarged.Sheaskshermother-in-lawifsheisinagreement.Themother-
in-lawanswersherthatshewillhelpandthatshewillreassuretherestofthefamily.
CaseStudy2Hawabreastfeedsher2-month-oldwhenhestartstocryandwhenhewakesup.Asitishot,Hawaalso
givesthebabywaterusingafeedingbottle.
TheCommunityVolunteer
TheCVneedstoaskandlistentothecurrentpracticeandidentifyproblemsandcausesforthe
problems.
Inthisparticularcase,themainproblemisthatHawadoesnotrealizethatbreastmilkistheonlysource
ofwateraninfantunder6monthsneeds.TheCVdiscusseswithHawathatupto6months,theinfant
shouldonlydrinkbreastmilk.Sheexplainsthat themother'smilkcontainsallthewaterandallthe
foodsthatthebabyneeds tosatisfythebabyshungerandthirstandthereforedoesnotneedany
additionalfluidsorliquids.TheCValsoexplainsthatbabieslessthan6monthsmustbebreastfedevery
timetheyarehungryorthirsty,duringthedayandthenight, atleast10to12timesperday.Themore
frequentlythemotherbreastfeeds,themoremilksheproduces.Finally,theCVrecommendstoHawato
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neverusefeedingbottlestofeedthebabybecausetheyaredifficulttocleanandcancausethebabyto
havediarrhea.
TheCVasksHawawhatproblemsshethinkssheislikelytoencounterifshedoesnotgivethebaby
watertoday.Hawaanswersthatherhusbandbelievesthatthebabyneedswater.TheCVaskstospeak
withthehusbandandachildissenttogethim.Hecomestolisten.TheCVexplainstohimthatGodput
allthewaterthebabyneedsinthemothersmilkandthatgivingwatertobabieslessthan6monthsofageallowsgermscarryingdiseasetoenterthebabysstillweakbody.Inaddition,whenthebabys
stomachisfilledwithwaterthebabysuckslessonthebreast,whichreducesthemothersmilk
production.ThehusbandlistenstowhattheCVissayingandafteramomentthehusbandsaystohis
wife,TheCViscorrect.IheardthesesamewordsontheradioandtheHealthWorkerssaidthatour
practiceofgivingwatertobabiesisbad.Accordingtothem,thispracticeistheprincipalcauseof
malnutritioninourarea.Wewillstopgivingwatertoourbabyuntilheis6months.
CaseStudy3Kortugivesonlybreastmilktoher3-month-oldbaby.Sheisthinkingofintroducingriceporridgetothe
babybecauseshefeelshermilkisdecreasing.
TheCommunityVolunteer
TheCVneedstoaskandlistentothecurrentpracticeandidentifyproblemsandcausesforthe
problems.
Inthisparticularcase,themainproblemisthattheinfantisexperiencingagrowthspurtandmustbe
givenmorebreastmilk.TheCVexplainstoKortuthatshewillhaveenoughmilkif shebreastfeedsmore
frequently,whichwillincreasehermilkproduction.TheCValsoexplainsthat until6monthsofagethe
babyshouldonlybegivenbreastmilk. Breastmilkcontainsallthewaterandfoodsthatthebabyneeds
tosatisfythebabyshungerandthirst.Itisthusnotnecessarytogivethebabyanyotherliquidsduring
thefirst6monthsoflife.Kortushouldbreastfeedthebabyeverytimethebabyishungryorthirsty,at
least10-12timesoveronedayandnight.TheCVsaysthisrecommendationisoftengivenbyhealth
workerswhenthereisareductioninthemothersmilkandasksifKortucanfollowit.Kortuacceptsbut
sheseemsratherhesitant.Shelowershereyesthenlooksovertoherhusbandseldersister.TheCV
explainsthatforthenext2weeks,sheshouldputthebabytothebreastmorefrequentlyandensure
thatthebabyemptiesonebreastbeforesheswitchestotheotherbreast.Shewillseethathermilk
productionwillincreaseandthatthebabywillbesatisfiedattheendofafewdays.Thesister-in-lawhas
followedthewholeconversationandtheCVasksherwhethersheagreestosupportKortusdecision
nottogiveporridgetothebaby.Shesaysthatshewillandthatshewillexplaintothehusbandandthe
grandmother.Kortusmilesandsaysthatshewilltrytobreastfeedthebabymorefrequentlytohelp
increasehermilkproductionandthatuntil6monthsofageshewillonlygivebreastmilktothebaby.
TheCVpromisestoreturnforafollowupvisitinfourdaystoseehowsheisdoing.Kortugivesasighof
reliefandthankstheCV.
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CaseStudy4Kebbehis35yearsoldandhasfivechildren.Sheisbreastfeedingheryoungestchild,whois18months.
TheCommunityVolunteer
TheCVhastoaskandlistentothecurrentpracticeandidentifyproblemsandcausesfortheproblems.
Inthisparticularcase,themainproblemisthatKebbehhadmanychildrenandsheisstillbreastfeeding.Sheisprobablyweakfromhavingsomanypregnancies/breastfeeding.TheCVneedstoexplainthe
importanceofeatingwell,eatingtwoadditionalmealseachday,withmanydifferenttypesoffoodsas
muchaspossible,particularlymeat,fruits,andvegetables,andtouseiodizedsaltforherandher
familysfood.ShealsoshouldencourageKebbehtoseekfamilyplanningtopreventadditional
pregnancies.
TheCVasksherwhethershereceivedirontabletsduringherprenatalvisits.Sherepliesthatsheforgot
totakethemafterthebirthofherbabyandthatshestillhastabletsforthreemonths.TheCVasks
Kebbehtoshowherthetablets.TheCVrecommendsKebbehcontinuetotakethemuntiltheyare
finished.TheCVasksifherhusbandcouldbuyhersomeliveronceaweek.Kebbehconsultshermother,
andhermotherassuresKebbehthatshewillaskthehusbandtodoitandexplaintohimthatKebbeh
willnotbehealthyunlessheranemiaistreated.TheCVthenpromisestofollowupwithanothervisitatthebeginningofthenextweektoseehowtheyaredoing.KebbehandhermotherthanktheCVand
assureh/sheismostwelcomenextweek.
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SESSION5
SCREENINGFORMALNUTRITION
LearningObjectives
Bytheendofthesession,participantswillbeableto:
Identifyachildwhoismalnourished(ortoothin). Knowwhenandhowtoreferachildfortreatment. Knowhowtocompletethetallysheetafterthemalnutritionscreeningsession.Overview
Activity5.1 Howdoweidentifyaseverelymalnourishedchild
Activity5.2 Describethestepsinreferringaseverelymalnourishedchildfortreatment
Activity5.3 Howtocompletethemonthlytallysheet
TotalTime 2hoursMaterials
MUACtapes(oneperparticipant) ChildMUACmeasurementposter(FacilitatorsNote9) 4-6children6-59months(providebiscuitsforthem)(ifchildrenarenotavailable,usetheadultMUACforparticipantstopracticewitheachother)
FacilitatorsNote10:Whentorefer
FacilitatorsNote11:Copiesofreferralcards(oneperparticipant),mostofthetimeprovidedbyMOH
(CMAMprogram)
FacilitatorsNote12:MonthlyTallyReports(oneperparticipant)
Activity5.1 WhatistheMUACtapeandhowisitused?
(45minutes)
Methodology:Facil itateddiscussion(15minutes) PassaroundoneMUACtapeperparticipant(theywillkeepthem). Askifanyoftheparticipantshasseen,orused,atapelikethisbeforeandwhatitisusedfor. ExplainthattheMUACtapeisusedtomeasurethinnessandthatitshouldalwaysbeusedonthe
leftarm.
Holduponetapeandaskaparticipanttodescribethedifferentpartsofthetape:1. Thetapehasawidesideandanarrowside
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2. Thewidesidehasaholeandthenarrowendofthetapeisdividedintothreecolors(green,yellow,andred).
Ameasurementinthegreenzonemeansthechildisproperlyfedandsothenutritionisgood
Ameasurementintheyellowzonemeansthechildisnotproperlyfedorissickandthenutritionisinthedangerzone.Thischildsmotherorcaretakershouldbecounseledonincreasedfeedingandthechildfollowedup.
Ameasurementinthe redzonemeansthechildisverypoorlyfedandbadoffandisintheverydangerouszone.Thischildcoulddieifnothingisdonesothechildshouldbereferred
quick-quickfortreatment.
ExplainthatthechildMUACtapeshouldonlybeusedwithchildrenover6monthsandunder5yearsofage.
Explainthatthemeasurementisdoneonthemiddleoftheupperarm. AskaparticipanttodescribehowtousetheMUACtape;refertothepictureontheFacilitators
Note8.
DemonstratehowtouseMUACwithachildunder-fiveorwithaparticipantusinganadultMUACbyfollowing:1. Askthemotherorthecaretakertoremoveallclothingthatmaycoverthechildsleftarm.2. Findthemidpointofthechildsleftupperarm
Locatethetipofthechildsshoulderwithyourfingertips Bendthechildselbowtomakearightangle Usingastring,measurethetipoftheshouldertothetipoftheelbowandfoldthestringin
half.Markthehalfwaypointmid-pointonthechildsarm.
3. Straightenthechildsarmandwrapthetapearoundthearmatthemidpoint.4. Inspectthetensionofthetapeonthechildsarm.Makesurethetapehasthepropertensionandisnottootightortooloose.5. Identifythecolorbetweenthetwoarrowsandimmediatelyrecordthemeasurement.
Methodology:Demonstrationanddiscussion(30minutes) Divideparticipantsintogroupsoffour. GiveeachgroupaMUACtape,twine,andachildtopracticewith. Eachpersonineachgrouppractices,measuringtheMUACofthechild(ortheirpartner)following
thecorrectsteps.
Aftereveryonehastakenaturn,askparticipantstosharetheirexperiences. DiscussthecommonmistakesthatcanbemadewhenusingaMUACtape.Theseare:
Wrappingthetapetootightlyortooloosely Nottakingthemeasurementatthemid-pointbetweentheshoulderandelbow Takingameasurementwhenthechildstillhasitselbowbentornotrelaxed Takingameasurementontherightarmratherthantheleftarm
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FacilitatorsNote9
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Activity5.2 Referachildwhoneedsspecialattention
(1hour)
Methodology:Facil itateddiscussion(15minutes) Asktheparticipantswhyandwhentheyshouldreferachildtoahealthfacility. Asktheparticipantswhyandwhentheyshouldfollow-uptoensurethechildreceivedtreatment. MakesurethatallthepointsonFacilitatorsNote9arecovered,andsummarizethem.FacilitatorsNote10
Whentoreferachildtoahealthfacility
If : thechildsMUACcolorcodeis yellow:thechildneedsspecialcounselingandcanbereferredto
supplementaryfeedingifavailable;
thechildsMUACcolorcodeis red:verydangerous,andthechildneedstreatment; thechildhasoedema(bothfeetswollen): extremelydangerous,andthechildneedsimmediate
treatment;
thechildhasdiarrhea: 1. Thechildisnotimproving2. Thechildisunabletodrinkorbreastfeed3. Thereisbloodormucusinthestool4. Thechildisveryweak
thechildhasafeverandis:1. Vomiting2. Veryweak(cannotsitorstandwithouthelp)3. Jerkingorhasastiffneck(convulsing)4. Notabletobreastfeed
thechildhasanyotherillness;or thechilddoesnothaveaChildGrowthCard.Encouragethemothertogotoahealthfacilitiesfor
thechildtohavenutritionfollow-up.
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Methodology:Demonstrationanddiscussion(45minutes) Explaintoparticipantshowtousethereferralcard. Showparticipantstheflipchart/referralcard(FacilitatorsNote10)anddescribethedifferentparts
andhowtofillthemout.
Discusswiththeparticipants: Whatshouldyoutellthemotherwhosechildyouarereferringtoahealthfacility?Whatshould
youdoafterthechildhasbeenreferred?
Whydoyouneedtofollow-uponachildwhohasbeenreferred? Makesureallthepointsarementioned:
Themotherneedstoknowthereasonwhysheisbeingreferredtoahealthfacilityandwhatshouldhappenwhenshegetsthere.Thereferralcardwillallowhertoseeahealthworkervery
quickly.
Afterthechildhasbeenreferred,theCommunityWorkersshouldfollow-uptomakesurethatthechildhasbeentakentoafacilityandgetsappropriatetreatment.
Afterthechildhasbeentreatedatthefacility,s/hewillbesentbacktothecommunitywithfollow-upinstructions.Thiswillincludeinstructionsonfeeding,whentoreturnforfurtherrations,andotherneededcare.Themother/caretakershouldbringthisformtotheCommunity
Workerssotheycanexplainitscontentsandreinforcethecounselingmessages.
Usingcasesstudies,participantspracticereferingachildtoahealthfacilityforfurtherassistance:
Inpairs,participantscompletethereferralformbasedontheinformationinthecasestudies(FacilitatorsNote10).Theparticipantspracticethereferralprocessusingthecompletedreferral
card.Thefacilitatorobserveseachpairinsilenceandgivesfeedbackthereafter.Theparticipants
changerolesandcontinuepracticingthereferralcardbychangingthecasestudies.
CaseStudy1
Musuisgirlof18monthsfromSuakokotown,SuakokodistrictinBongCounty.Shehasbeenattending
monthlyscreeningsessionsregularlyforthepast4months.Forthepast2months,Mususweighthasbeenintheyellowzone.Thismonth,herMUACdropped.Hermothersaysshehashaddiarrheaforthe
pastthreedays.HerMUACisintheRedZone.
CaseStudy2
Mathewisaboyof13monthsfromLittleKola,District4inGrandBassa.Mathewhasnotbeendoing
wellforawhileandhismotherhasnotbroughthimtothepasttwonutritionscreeningsessions.His
MUACisintheyellowzoneandhehasswellinginbothfeet.
Aftertheobservation,thefacilitatorleadsthediscussionbyaskingthefollowingquestions:Whathappened?Willthemothergototheclinic?WhatelsecouldtheCommunityVolunteerhavesaidto
encouragethemothertogototheclinic?
Thefacilitatorreviewsthereferralprocess.
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FacilitatorsNote11
COMMUNITY-LEVELREFERRALFORM
NAME:_____________________________________________
Community:________________ District:___________________ County:____________________
NameofClient:________________________________ Age:_____________ Sex:______________ReferredTo:______________________________________________________ReasonForReferral
1 Diarrhea/RunningStomach 2 MalariaorFever 3 Cough(ARI) 4 Malnutrition/ 5 FamilyPlanning 6 OtherDiseases
DateofReferral:___________________________________________________ReferredBy:______________________________________________________
Signature
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Activity5.3 TheMonthlyTallyReport
(15minutes)
Methodology:Facil itatedDiscussion(15minutes) Sharecopiesofthetallysheetanddiscusswiththeparticipantsthefollowing:
1. Whatinformationdowecollectonthetallysheet?2. Whenandhowoftendowecollectthisinformation?3. Whatdowedowiththeinformationafterwehavecollectedit?
Explainthedifferentpiecesofinformationcollectedonthesheet.
FacilitatorsNote12
MALNUTRITIONSCREENINGTALLYSHEET
DISTRICT__________________VILLAGE____________________ Month__________________
From______/_____/_______to______/______/______
NameSignature
____________________________________
MUACRED
MUAC
YELLOW MUACGREEN Oedema ooooo ooooo ooooooooooooooo ooooo
ooooo ooooo ooooooooooooooo ooooo
ooooo ooooo ooooooooooooooo ooooo
ooooo ooooo ooooooooooooooo ooooo
ooooo ooooo ooooooooooooooo ooooo
ooooo ooooo ooooooooooooooo ooooo
ooooo ooooo ooooooooooooooo ooooo
ooooo ooooo ooooooooooooooo ooooo
ooooo ooooo ooooooooooooooo ooooo
ooooo ooooo ooooooooooooooo ooooo ooooo ooooo ooooooooooooooo ooooo
ooooo ooooo ooooooooooooooo ooooo
ooooo ooooo ooooooooooooooo ooooo
ooooo ooooo ooooooooooooooo ooooo
6-59months
ooooo ooooo ooooooooooooooo ooooo
TOTAL
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SESSION6
COMPLEMENTARYFEEDING:
FEEDINGASICKCHILD
LearningObjectivesBytheendofthissession,participantswillbeableto:
Describekeyfeedingpractices. Explainthekeypracticesandmessagesforoptimalcomplementaryfeeding. Explainthekeymessagesforthesickand/ormalnourishedchild. Explainlocallyavailablefoodsandseasonallyavailablefoodsforoptimalcomplementaryfeeding.Activities
Activity6.1 Discusskeycomplementaryfeedingpractices(1hour)
Activity6.2 Identifylocallyavailablefoodsandseasonallyavailablefoodsforadequate
complementaryfeeding(1hour)
To ta lTime 2 h our s3 0min ute sMaterials
Flipcharts,paper,markers,maskingtape BookletonkeyENAmessages FoodpurchasedatlocalmarketIllustration12 IntroductioncomplementaryfeedingIllustration13 Continuebreastfeedinguntil2yearsandbeyond
Illustration14 Feedavarietyoffoods
Illustration15 Frequencyoffeedingfor6-11montholdchildren
Illustration16 Amountoffoodfor6-11montholdchild
Illustration17 Frequencyoffeedingforthe12-24montholdchildren
Illustration18 Amountoffoodfor12-24montholdchildren
Illustration19 Feedingofthechildduringillness
Illustration20 Feedingofthechildafterillness
Illustration21 Feedingofachildwithdiarrhea
Illustration22 Counselingforachildwithmoderateorsevereacutemalnutrition
Illustration23 ImportanceofVitaminA
Illustration24 Preventanemiafromparasites
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ACTIVITY6.1 Keycomplementaryfeedingpractices
(1hour30minutes)
Methodology:DemonstrationanddiscussionIntroductionofcomplementaryfoodsandcontinuationofbreastfeeding
ShowIllustrations12and13. Asktheparticipantstoanswerthequestionsontheillustrations. Readthemessageanddiscusstheadditionalinformation. Asktheparticipantstodiscussthemessagesandadditionalinformation,comparetocurrent
practices,andhowtoconvincethatthepracticecanimprovethehealthofmothersandchildren.
Fooddiversity
ShowIllustration14. Asktheparticipantstoanswerthequestionsontheillustration. Readthemessageanddiscusstheadditionalinformation. Asktheparticipantstodiscussthemessagesandadditionalinformation,comparetocurrent
practices,andstrategizehowtoconvincecaregiversthatthepracticecanimprovethehealthof
mothersandchildren.
Feedingchildren6-11months:frequencyandamount
ShowIllustrations15and16 Answerthequestionsontheillustrations. Readtheadditionalinformation. Comparetocurrentpractices,anddiscusshowtoconvincecaregiversthatthepracticecanimprove
thehealthofmothersandchildren.
Feedingchildren12-24months:frequencyandamount
ShowIllustrations17and18. Answerthequestionsontheillustrations. Readtheadditionalinformation. Comparetocurrentpractices,anddiscusshowtoconvincecaregiversthatthepracticecanimprove
thehealthofmothersandchildren.
Thefacilitatorsummarizesbyexplainingthemeaningof BF+FADDUA
Breastfeeding
+
Frequency+Amount+Density+Diversity+Utilization+Activefeeding
Feedingofasickchildduringandafterillness
ShowIllustrations19and20. Answerthequestionsontheillustrations. Readtheadditionalinformation. Comparetocurrentpractices,anddiscusshowtoconvincecaregiversthatthepracticecanimprove
thehealthofmothersandchildren.
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Feedingofasickchildwithdiarrheaorwithmalnutrition
ShowIllustrations21and22. Answerthequestionsontheillustrations. Readtheadditionalinformation.
Comparetocurrentpractices,anddiscusshowtoconvincecaregiversthatthepracticecanimprovethehealthofmothersandchildren.
VitaminA,malaria,andwormmedicine
Showillustrations23and24. Answerthequestionsontheillustrations. Readtheadditionalinformation. Comparetocurrentpractices,anddiscusshowtoconvincecaregiversthatthepracticecanimprove
thehealthofmothersandchildren.
ACTIVITY6.2 Identificationoffoods(purchasedlocallyatthemarket)
appropriateforinfantsandyoungchildren
(1hour)
Methodology:Facil itateddiscussion Eachparticipantisgiventwoormorefoodspurchasedlocallyatthemarketorpicturesoffoods(a
glassofwaterrepresentingbreastmilkandpictures/modelsofabreastrepresentingbreastmilkare
alsodistributed).Useallsortsofvegetables,differenttypesofmeat,chicken,fish,driedfish,beans,
plantains,nuts,flour,palmoil,VitaminA-fortifiedoil,papaya,mangoes,andlemonsetc.
Ontablesorthefloor(coveredwithcloth)facilitatorexplainsthattherearethefollowingthreeagecategories:
0-
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Methodology:GroupDiscussionDiscusshowtoencouragefamiliestokeepsomethingfromtheharvest"tofeedchildrenandwomen
(30minutes)
Divideparticipantsintothreegroups. Askthemtodiscusswheretheycanfindsimilartypesoffoodsintheirenvironment(home,garden,
market);
Whyitisimportanttokeepsome"harvest"toimprovefeedingpracticesforchildrenandwomen?
Askhowmuchtheycankeep? Howtheycanimprovethecurrentsituation?
Askthemtogiveexamples. Askthemtogiveexamplesonwhatcouldbeaddedtotheirgardens(e.g.,pumpkin,eggs,papaya,
bananatree,chicken,etc.).
Discusswhatassistancetheycouldgetfromtheagriculturesectors. Askeachgrouptopresentthemainideas.
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SESSION7
HOWTONEGOTIATEWITHMOTHERS,CAREGIVERS,FATHERS,
GRANDMOTHERS:COMPLEMENTARYFEEDINGANDTHESICKCHILD
Methodology:Learningtousethestepsofnegotiationforadequatecomplementaryfeeding(2hours) Usingcasestudies,participantspracticenegotiationskillstopersuadethemothertotryanewpractice.
Thefacilitatorobservestheparticipantsandencouragesthemtoimprovetheirperformance.
1. Demonstratehowtonegotiateandencourageamothertotryanimprovedcomplementaryfeedingpractice.Usetheroleplayonthenextpage.Discussthestepsfornegotiation. Usevisual
aids.
2. Inpairs,participantspracticethenegotiationskillsusingthecasestudies(FacilitatorsNotes13and14).Asupervisororfacilitatorobserveseachpairinsilenceandgivesafeedbackthereafter.
Theparticipantschangerolesandcontinuepracticingthenegotiationskillsbychangingthecase
studies.Eachparticipantneedstopracticenegotiationsoncomplementaryfeedingandfeedingofthesickchild.
3. Aftertheobservation,thefacilitatorleadsthediscussionbyaskingthefollowingquestions:Whathappened?Willthemothertrythispractice?WhatelsecouldtheCommunityVolunteer
havesaidtoencouragethemothertotrythepractice?
4. Thefacilitatorreviewsthestepsofnegotiation.5. Thefacilitatorexplainsthatmorethanonevisitisneededforthefullprocessofnegotiation.
Atleast2visits:
Initialvisit Follow-up:after1to2weeks Ifpossible,athirdvisittomaintainthepracticeornegotiateanotherpractice
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FacilitatorsNote13
PracticeCaseStudies:Complementaryfeeding
CaseStudy1Korpohasa7-month-oldbabythatsheisbreastfeeding.Korpothinksthatherbabyistooyoungtoeat
thickporridge,soshegiveshimliquidporridge,whichshedoesnotenrich.
TheCommunityVolunteer
TheCVexplainsthatstartingfrom6monthsbabiesneedtoeatporridgeinadditiontothemother's
milk.Thisporridgecanbepreparedusingrice,cassava,plantain,maize,yam,etc.anditmustbe
sufficientlythickinconsistencyandnottoorunny(sticktothespoon).Itshouldbeenrichedwithvarious
andcolorfulfoodsthathavebeenmashedtohelpthebabyswallowit.Cassavaleaves,sesameseeds,
banana,aswellasmilk,meat,fish,beans,andpeanutsornutscanbeusedtoenrichtheporridge.At
eachmeal,Korpocanaddpalmoilorpeanut/sesameseedpastetothebabysfoodasthesefoodsare
goodforthebaby.TheCVcongratulatesKorpoforhavingcontinuedbreastfeedingandrecommendsshe
continuestobreastfeeduntilthechildisatleast2years.
CaseStudy2Bettyhasa6-month-oldbaby.Sheisthinkingofstartingtogiveadditionalfoodtoherbaby.Shethinks
thebabyonlyneedsporridgemadefromeddoedust.
TheCommunityVolunteer
TheCVexplainsthatfrom6months,babiesneedtoeatthickporridge(sticktothespoon)inadditionto
themother'smilk.Thisporridgecanbepreparedusingrice,cassava,plantain,eddoes,yam,etc.TheCV
explainsthatstartingat6months,itiswisetogiveasmanyvarietiesoffoodaspossibletothechild.TheCVexplainsthattohelpthebabygrowwell,Bettycanenricheachmealofporridgebyaddingtwoor
threekindsoffoodthatshehasinthehousetoit.Shecanenrichtheporridgebyaddingpalmoil,benne
seeds,orpeanutpastetoeachmeal.Sheshouldalsogivefruit(orange/redcoloredfruit)orcassava
leavestoeachofthebabysmeals.Everyday,sheshouldtrytoaddmeat,fish,beanflour,or
peanuts/benneseedtothebabysfood.Shecanalsousemilktocooktheporridgeinsteadofwater,if
possible.Themeat,chicken,orfishshouldbemashedorpureedbeforefeedingittothebaby,anditis
importanttoenrichthebabysfoodasoftenaspossibletosupportpropergrowthanddevelopmentof
thebaby.Bettyshouldalsocontinuetobreastfeedthebabyondemandforatleasttwoyears.Betty
tellstheCVthatshehasvegetables,fruits,palmoil,andbeans.Sheagreestoenrichthebabysporridge
ateachmealandtocontinuetobreastfeedatleasteighttimesaday.
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CaseStudy3 Quetahasan8-month-oldgirl,whomshefeedsporridgeenrichedwithvariousdifferentfoodseachday.
However,itseemsthatthebabyishungrythisafternoon.
TheCommunityVolunteer
TheCVexplainsthatfrom6to11months,ababycanbegivensoftenrichedthickporridgeatleast3timeseveryday,inadditiontobreastmilk.Ineachmeal,Quetasbabycaneatatleast2tablespoonsof
porridgeenrichedwith1tablespoonofvariouscolorfulfoods.Shecanevengiveherdaughtermoreif
sheseemshungry,asitishealthyforherbabytoeatasmuchfoodaspossible,particularlyavarietyof
foods.TheCVadvisesQuetatobepatientandtotakehertimewhenfeedingherbaby,actively
encouraginghertoeatallthefoodgiven.TheCValsoexplainstoQuetathatinadditiontoporridge,the
babyshouldbegiven1-2snacks(biscuits,banana,mango,etc.)everydayinbetweenthefeedingof
porridge.Thiswillhelpthebabytogrow.Quetaappreciatestheadviceandagreestotrythe
recommendedpractices.
CaseStudy4Kebbehhasa7-month-oldbaby,whomshebreastfeeds.Shealsogivesherbabyathinliquidporridge
andinfantformula.Sheputsthisthinliquidporridgeinafeeding-bottletofeedthebaby.Kebbehdoes
notthinkthatherbabyisreadytoeatotherfoods.
TheCommunityVolunteer
TheCVexplainstoKebbehthatat6monthsofage,babiesneedtoeatadditionalfoodssuchasthesoft
porridge,inadditiontobreastmilk.TheCVexplainsthatbabieswillnotgrowwellifonlygivenathin
liquidporridge.Theporridgeneedstobethickenoughthatitcansticktothespoonandshouldalsobe
enrichedwithtwoorthreeothertypesoffoodsavailableinthehouse:cassavaleaves,sesameseeds,
banana,aswellasmilk,meat,fish,groundnuts,beansornutscanbeusedtoenrichtheporridge.At
eachmeal,Kebbehcanaddpalmoilorpeanutpastetothebabysfoodasthesefoodsaregoodforthe
baby.TheCVadvisesKebbehnevertousefeedingbottlesastheyveryhardtocleanproperlyandcancauseherbabytogetdiarrhea.Shealsonotesthatinfantformulaisexpensive,anditisbetterinsteadto
buysomefishormeatforthebaby.TheCVremindsKebbehtocontinuebreastfeedingondemand
betweenthemeals(atleast8times).KebbehisinagreementwiththerecommendationstheCVhas
madeandagreestogivethickporridgetothebabyandtostopusingthefeedingbottle.
CaseStudy5Saybasbabyboyis15monthsoldandeatsfamilyfoodswithhisparentstwotimeseachday.Saybais
nolongerbreastfeeding.Hersonseemstobesmallforhisage.
TheCommunityVolunteer
TheCVasksSaybawhyshestoppedbreastfeeding.Wasitbecausesheispregnantorisitsimplybecause
thebabystoppedbreastfeeding?TheCVremindsSaybathatthebabystillneedsbreastmilkuptoat
least2years.SheexplainstoSaybaforhersontostayhealthandgrowwellheneedstoeatmoreoften
(atleast5timesperday:3mealsplus2snacks),especiallysinceheisnotbenefitingfrombreastmilk.At
eachmeal,sheshouldgive6tablespoonsofporridgeenrichedwith3tablespoonsofotherfoodssuchas
cassavaleaves,sesameseeds,banana,vegetables,palmoil,aswellaseggs,milk,meat,fish,sesame
seedorpeanutpaste,beansornuts.TheCVrecommendsthatthebabysfoodshouldbeservedina
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separateplatebecausethiswillallowSaybatoseeifthebabyiseatingandfinishingtheamountoffood
thatheneedstogrowproperly.Andbecausethefamilyfoodisnotsufficientlyenrichedtomeetthe
babysneeds,Saybashouldaddtheseotherfoods.Assnacks,Saybacangivefruits(banana)orbiscuits
betweenthemealsthebabyeatswithhisparents.Theadditionalfoodsandsnackswillmakethebaby
strong.Finally,theCVadvisesSaybatotrybreastfeedingagainuntilhersonisatleast24months,
especiallysinceshehadonlystoppedbreastfeedingafewdayspreviously.Saybaappreciatestheadvice
fromtheCVandagreestotrytoapplyit.
CaseStudy6Massasdaughteris11monthsoldandshegivesherthinporridge.Massabreastfeedsherdaughteronly
atnight.
TheCommunityVolunteer
Massaisadvisedthattheconsistencyoftheporridgeshouldbethickenoughtosticktothespoon.This
porridgecanbepreparedusingrice,cassava,millet,maize,plantain,yam,etc.anditmustbesufficiently
thickinconsistencyandnotsorunnyitrunsoffthespoon.Itshouldbeenrichedwithvariousand
colorfulfoodsthathavebeenmashedorgrounduptohelpthebabyswallowthem.Foodssuchas
cassavaleaves,sesameseed,banana,aswellasmilk,meat,fish,peanuts,beansornutscanbeusedto
enrichtheporridge.Ateachmeal,Massacanalsoaddpalmoilorbuttertothebabysfoodasthese
foodsaregoodforthebabyaswell.TheCValsoexplainsthatinadditiontofeedingporridge,Massa
shouldalsogiveherbabyonetotwosnackseverydayinbetweenthefeedingofporridge.Massais
advisedtocontinuetobreastfeedonthebabysdemand,atleast8timesduringthedayandnight,until
herbabyis2yearsofage.Massaishappyandagreestotrywhattheydiscussed.
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FacilitatorsNote14
PracticeCaseStudies:Feedingofthesickchild
Roleplaybyfacil itator(s) Miattassonis10monthsoldandhasdiarrhea.Miattastoppedbreastfeedingbecauseshethinksthat
milkworsensthebabysdiarrhea.
TheCommunityVolunteer
TheCVexplainstoMiattathatitisevenmoreimportantthatshebreastfeedsherbabyduringandafter
theillness.Thishelpsthebabytomakeupforthelossinwaterandenergy,limitshisweightloss,and
helpsthebabytorecoverfaster.Sincethebabyismorethan6monthsofage,theCVadvisestogivea
glassoforalrehydrationsolution(ORS)aftereachepisodeofdiarrhea.TheCVadvisesMiattatotryto
increasetheamountofenrichedporridgeduringtheillnessandtoalsogivethebabyanadditionalmeal
eachdayfor2weeksafterthebabyhasrecoveredtoallowthebabytoregainquicklyanyweighthelost
duringtheillness.TheCValsorecommendstoMiattatotakethebabytothenearesthealthfacilityifthediarrheapersists.TheCVandthemothertalkabouttheproblemssheislikelytoencountertryingto
gettothehealthcenterandlookforappropriatesolutions.
CaseStudy1Hannahs3-month-oldbabyhasdiarrheaandisvomiting.Themotherisstillbreastfeedingbuthasalso
beengivingwatertothebabyinabottle.
TheCommunityVolunteer
HannahisadvisedbytheCVthatherbabyshouldbefedonlybreastmilkforthefirst6monthsoflife,
notgivingwater,otherliquidsorfoodsasbreastmilkaloneprovideseverythingababyneedstogrowhealthyandstrong.TheCVadvisesHannahtostopgivingwaterandnevertousebabybottlesasthese
arehardtokeepcleanandcontaingermsthatwillcausediarrhea.ShealsoadvisesHannahto
breastfeedmoreoftenwhenherbabyissickaswellasmoreoftenafterthesicknesstohelpthebaby
recovermorequicklyandstarttogainweight.Hannahistoldtotakethebabytothehealthcenteras
soonasshecan.Hannahisgratefultohavethisadviceandplanstofollowit.
CaseStudy2Joycesdaughteris9monthsold.Thebabyhasamildfeverandcough,andinaddition,refusestoeat
food.
TheCommunityVolunteer
TheCVadvisesJoycetotaketimetopatientlyencourageherbabytoeatasherappetitemaybelower
becauseoftheillness.Sinceherdaughterisolderthan6months,Joyceisadvisedthatsheshould
increasethefrequencyofbreastfeeding,andalsoofferthebabysfavoritefoodduringillness.She
recommendsgivingthedaughteroneadditionalmealofenrichedporridgeeachdayforthe2weeks
followingtheillnessandtoincreasethefrequencyofbreastfeedingafterthebabyseemsbetter.Joyce
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agreestofollowtheadviceoftheCV.TheCValsoadvisesthemothertovisitthehealthcentertoget
treatment.
CaseStudy3Bettysbabyboywassicklastweekandisnowrecoveringfromtheillness.Heis5monthsold.Bettycontinuestobreastfeedasusual,butherbabyislosingweight.
TheCommunityVolunteer
Bettyisadvisedthattohelpherbabyrecoverfromtheillnessandgainweight,sheshouldincreasethe
numbersoftimesshebreastfeedsbothduringandaftertheillness.Bettyagreestotrytheadvicegiven
bytheCV.
CaseStudy4Faithhasababywhois9monthsold.FaithtellstheCVthatherbabyisrecoveringfromanillnessand
hasstartedeatingwellbutisstilllosingweight.TheCommunityVolunteer
TheCVadvisesFaiththataftereveryillness,herbabywillneed1additionalmealeachdayfor2weeksin
additiontothe3dailyfeedingsofenrichedporridge.ShealsoadvisesFaithtogivesnacksonetotwo
timeseachday,suchasbanana,biscuits,orbread,inbetweenthefeedingsofenrichedporridge.In
addition,sheshouldalsobreastfeedherbabymoreafterillnesstohelprecovermorequickly.Faith
agreestotrythisadvice.
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SESSION8
FIELDPRACTICE
LearningObjectives
Attheendofthesession,theparticipantswillbeableto:
Usenegotiationtechniquesinthefield,inthehealthcenters,orinthevillages. Evaluatethebreastfeedingpractices. Evaluateadditionalfeedingpractices.Overview
Activity8.1 Fieldpracticeatthehealthcentersorvillages(2hour30minutes)
Activity8.2 Feedbackonthepracticalsession(45minutes)
Activity8.3 Demonstrationofafollow-upvisitinclass(15minutes)
To ta lTime 3 h our s3 0min ute sNumberofpeopleonthesite:8to10,toconstitute4to5pairs
DescriptionoftheSites
Healthclinicatthetimeofvaccinationorweightrecordingsession Sickbabyclinicvisits/IMNCI Maternitywards/ANC Growthmonitoring/nutritionscreeningandpromotionsites Communitygroupings Motherswithinfants0to6monthsoldand/orpregnantmothers Motherwithinfants6to24monthsoldand/orlactatingmothersMaterials
Visualaids:posters,notebooks/cards,healthrecords,counselingcards BookletwithkeyENAmessages
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ACTIVITY8.1 Fieldpracticeinthehealthcentersorinthevillages
(2hours30minutes)
Methodology Inplenary,reviewthestepsofnegotiation. Grouptheparticipantsintopairs.Duringthefieldpractice,theparticipantswilltaketurns
role-playingthepartsofthenegotiatorandthatoftheobserver.Thenegotiatorwillconduct
thecounselingandnegotiationwiththemotherandtheobserverwillobservewiththe
objectiveofgivingfeedback,usingGALIDRAAafterthemotherhasleft(FacilitatorsNotes4
and5).
Theparticipantswillexchangerolesuntileachofthemhascompletedatleastthreenegotiationsandtwoobservationsofnegotiationswithbreastfeedingmothers.
ACTIVITY8.2 Feedbackonthefieldpractice
(45minutes)
Methodology Backinclass,eachpairwillsummarizetheirexperiencewiththepracticeofnegotiationby
givingareportononeexampleusingthefollowingformat-theywillindicatethename(s)of
theparticipant(s),thenameandageofthechild,theproblemtheyveidentified,the
proposedsolutions,andthebehaviorthatthemotherhasagreedtoadopt.
Theparticipantslistentothefeedbackprovidedbytheirpeersandgivetheirown. Discussionandsummary.ACTIVITY8.3 Demonstrationofafollow-upvisit
(15minutes)
Methodology Facilitatorsdemonstratetheconductofafollow-upvisitofthecommunityagent(orhealth
agent)inthecaseofHawawhois2monthsold.
Fromthefieldvisitexperience,fivetosixparticipantsexplainwhattheywillfollow/discusswhentheywillcarryoutthesecondvisit.
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SESSION9
DEVELOPMENTOFACTIONPLANS
LearningObjectives
ToreviewthevariousactivitiesthroughwhichtheCommunityVolunteercontributestoimprovethehealthofwomenandchildren,aswellastheplacesandtheoccasionswhere
theycantakeadvantagetodothis.
Toidentifyconcretepointsofcontactthattheycanuseintheirdailyworkandworkoutaweeklyandthenmonthlyscheduleofwork.
Todevelopanactionplanfor3monthsandpresentittothewholegroup.Overview
Activity9.1 TheactivitiesofCommunityVolunteer(CV)thatcontributetoimprovingthe
healthofmothersandtheirchildren.PlaceswhereandoccasionswhentheCV
canspeakthem(30minutes)
Activity9.2 Developmentoftheactionplans(1hour)
Activity9.3 Post-testandcourseevaluation(30minutes)
Preparation
Ifpossible,invitecommunityleaders toattendtheactionplanpresentation.
TotalTime 2 hoursClosure
Distributionofbadgesandcertificates
ACTIVITY9.1 ActivitiesofCommunityVolunteerthatcontributeto
improvingthehealthofwomenandchildren.
(30minutes)
Methodology:Brainstorming Thefacilitatorpresentsthesevenessentialnutritionactionsandthekeycontacts. BrainstormtogetherwhatactivitiestheCommunityVolunteer(CV)candoinoneweek.Askin
whatinstanceswouldtheyvisitawoman?Whichtypesofwomendotheyvisit?Whatdothey
dointhatinstance?Thenaskthemtothinkofoccasionstheycantakeadvantageoftoshare
thethingstheyhavelearnedinthetraining.
RefertoFacilitatorsNotespages1and2
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ACTIVITY9.2 Developmentofathree-monthactivityplan
(1hour)
Methodology:Groupdiscussion Dividetheparticipantsintotheirrespectivezones(villages/communitiestheyserve). AsktheCVsiftheywillgotoallthehealthclinics,dogroupdiscussions,homevisits,visit
pregnantwomenandwomenwithchildrenunder2years.
Ensurethatthedecisionstakenarerealistic.TheCVsshouldconsiderthepossibility,forexample,ofmakingonehomevisitperweekforchildrenlessthan2yearsandcombiningit
withonevisitperweekwithapregnantwomanonthesameday.
Followingthediscussion,eachteamwilldecideontheirmainactivities. Eachgrouppresentstheirplanofactions(oralpresentation). Discussionwiththegroupsandsummary.ACTIVITY9.3 Post-testandtrainingevaluation
(30minutes)Methodology Askparticipantstoformacircleandsit(stand)sothattheirchairbacksarefacingthecenter. Proceedasforthepre-test. Comparetheresultswiththepre-testandpresenttotheparticipantsduringtheclosing
ceremony.
Writetheend-of-trainingevaluationsonaflipchartandasktheparticipantstocheckthecorrespondingbox:good,average,unsatisfactory.
ClosingCeremonyInvitekeymembersofthecommunity(healthcenter,schools,localadministration,villagechief,
etc).
Handoutcertificatestotheparticipants.
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END-OF-TRAININGEVALUATION
Placeatheboxthatreflectsyourfeelingsaboutthefollowing:
GOOD AVERAGE UNSATISFACTORYTrainingobjectivesmet Methodsused Materialsused FieldPractice Capacitytocarryoutanidentical
training(forTOT)
Teabreaks 1.Whichsessionsdidyoufindmostuseful?
2.Whatareyoursuggestionstoimprovethetraining?
3.Othercomments:
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ACTIVITY9.2 Developmentofathree-monthactivityplan
(1hour)
Methodology:Groupdiscussion Dividetheparticipantsintotheirrespectivezones(villages/communitiestheyserve). AsktheCVsiftheywillgotoallthehealthclinics,dogroupdiscussions,homevisits,visit
pregnantwomenandwomenwithchildrenunder2years.
Ensurethatthedecisionstakenarerealistic.TheCVsshouldconsiderthepossibility,forexample,ofmakingonehomevisitperweekforchildrenlessthan2yearsandcombiningit
withonevisitperweekwithapregnantwomanonthesameday.
Followingthediscussion,eachteamwilldecideontheirmainactivities. Eachgrouppresentstheirplanofactions(oralpresentation). Discussionwiththegroupsandsummary.ACTIVITY9.3 Post-testandtrainingevaluation
(30minutes)
Methodology Askparticipantstoformacircleandsit(stand)sothattheirchairbacksarefacingthecenter. Proceedasforthepre-test. Comparetheresultswiththepre-testandpresenttotheparticipantsduringtheclosing
ceremony.
Writetheend-of-trainingevaluationsonaflipchartandasktheparticipantstocheckthecorrespondingbox:good,average,unsatisfactory.
ClosingCeremonyInvitekeymembersofthecommunity(healthcenter,schools,localadministration,vil